Continuous versus Limited Duration CLL Therapy
In science and medicine, information is constantly changing and may become out-of-date as new data emerge. All articles and interviews are informational only, should never be considered medical advice, and should never be acted on without review with your health care team.
Bottom Line
There are multiple excellent choices between limited-duration and continuous targeted therapies that all can offer durable disease control. There are many considerations to balance when choosing between them.
Patient Considerations:
- Patient preferences: Some patients want to be off all CLL meds so they can forget about their leukemia and avoid the expense and possible side effects, while others might prefer the reassurance of taking daily medications to continuously knock their cancer back.
- Comorbidities: Conditions such as cardiac or renal disease can make some therapies riskier.
- Convenience: Some treatments demand frequent clinical and lab visits or even hospitalization to initiate therapy, which might be impractical and even impossible for some.
- Cost and insurance: What’s paid and what comes out of the patient’s pocket is often the decisive factor in choosing the treatment. Fixed duration might be more expensive in the short term due to the use of multiple drugs, but continuous therapies quickly become more costly long term due to the ongoing drug costs.
Research and Biologic Considerations:
- Data are sparse and early, but evidence from trials such as CLL17 demonstrated that fixed-duration therapy using venetoclax-based combinations is generally as effective as continuous BTK inhibitor therapy for first-line treatment of CLL.
- In CLL17, patients with high-risk features such as del17p do slightly better with continuous BTKi therapy, though it is not yet clear that there is a significant difference.
- All approved limited-duration therapies use two or more medications, and more drugs usually mean more side effects.
- The addition of the anti-CD20 antibody obinutuzumab can be associated with more infections.
- Though their biologic impact can persist (especially true for anti-CD20 antibodies obinutuzumab and rituximab), eventually, there are no side effects from a drug you have stopped taking.
- There is emerging evidence that limiting the exposure to CLL drugs by shortening the therapy may significantly lower the risk of developing resistance mutations and thus allow reuse of the same drugs if the patient should have a late relapse.
Conclusions:
There are no bad choices. New continuous and limited-duration therapies are coming, and the data are growing to help your decision. Start by knowing what’s important to you, discuss with your doctor about your unique situation, and finally make a shared decision to set your best path forward.
